Training the Impingement Client

By Chris Gellert, PT, MMusc & Sportsphysio, MPT,

CSCS, AMS
Introduction
The shoulder is a complex joint involved with everyday activities such
as reaching and sport specific movements. Evidenced based research
and my clinic experience as a physical therapist, supports that
shoulder impingement is a common movement dysfunction seen in
men. This article will review the following about shoulder
impingement:
Pathophysiology
Common signs and symptoms and contributing factors
Physical therapy management
Program design
Exercises that are contraindicated with rationale
Background
Pathophysiology/mechanism of injury: Shoulder impingement(SI) is the
mechanism in
which the supraspinatus tendon of the rotator cuff becomes impinged as it passes
through a
narrow bony space called the sub acromial space. With repetitive movement, the
supraspinatus
tendon can become irritated and inflamed. SI can also be caused by a decrease in
posterior
capsule mobility and weakness of scapulothoracic musculature. Evidenced based
research
has shown that shoulder impingement is a common condition believed to contribute
to the
development or progression of rotator cuff disease(Ludewig, P. 2011)
Decrease in sub acromial space comprises the supraspinatus tendon,
predisposing it
to micro tears leading to degeneration and ultimately tearing.
Tightness of the posterior capsule causes the humerus to migrate
anterosuperior into
the AC joint.
Weakness of scapulothoracic muscles leads to abnormal positioning of the
scapula.
Common signs and symptoms: Clients will complain typically of
pain in the front of the shoulder, described as deep, dull ache with
stiffness. Reaching overhead and behind ones back will elicit pain.

Figure 1. Painful arc

Contributing risk factors: Poor posture, repetitive overhead work,

and tight posterior capsule are some contributing factors. Per the
research, the development of SI has been correlated to abnormal
muscle activation. Specifically, those with SI, present with the
overactive upper trapezius and underactive lower trapezius muscles
(Chester, R., et al. 2010).
Physical therapy management:
The goal with physical therapy is to restore scapular mobility, followed
with stretching to restore full range of motion (figure 2).
Strengthening focuses on targeting the weaker upper posterior
musculature that includes rhomboids, low trapezius, external rotators
and serratus anterior muscles. Then patient is taught scapular
stabilization and dynamic strengthening exercises.

Figure 2. Manual
therapy by physical
therapist on
shoulder
Program design and exercise prescription for the impingement
client
Once discharged from physical therapy, transitioning to the gym
should be simple, and based on science, not guessing. The focus on
post rehabilitation training is to strengthen the scapular stabilizers
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(rhomboids, low trapezius, posterior deltoid and external rotators)

and posterior shoulder. Core strengthening should progress from
static to dynamic exercises.

Figure 5. Mid row

exercise

Figure 4. Low trapezius

Figure 3. Posterior
strengthening
capsule
stretching

Upper body exercises that are safe based on biomechanics

include:
Low trapezius pull downs (figure 4) with cable standing or
tubing, depresses and retracts the scapula, unloading the
anterior shoulder, improving posture and posterior stability.
Seated mid row, one arm dumbbell row, seated reverse flyes
(posterior deltoid) strengthens the weaker phasic muscles of the
posterior chain.
External rotation with cable, seated reverse flyes, seated
dumbbell side
raises.
Core strengthening exercises that are safe include but not
limited to; standing trunk rotation with cable/tubing, diagonal
with cable tandem in place lunge, planks, planks with ball, trunk
rotation with forward lunge.
Exercises that are contraindicated include with rationale:
Seated dumbbell shoulder press (creates excessive load to the
medial deltoid).
Lat pull downs behind the head (at end or range places greatest
stress on all
glenohumeral ligaments as well as on the labrum).
Upright row (at end of range-shoulder is maximally internally
rotated which places
stress on all glenohumeral ligaments, labrum and connective
tissue).
Summary:
Shoulder impingement is a common shoulder condition that a fitness
professional may encounter. Understanding the anatomy,
biomechanics and proper program design with evidenced based
training strategies, will provide you with a better understanding to
work with clients.
Chris is the CEO of Pinnacle Training & Consulting Systems(PTCS). A
continuing education company that provides educational material in
the forms of evidenced based home study courses, ELearning courses,
live seminars, DVDs, webinars, articles and teaching in-depth, the
foundation science, functional assessments and practical application
behind Human Movement. Chris is both a dynamic physical therapist
with 16 years experience, and a personal trainer with 20 years
experience, with advanced training, has created over 10 courses, is an
experienced international fitness presenter, writes for various
websites and international publications, consults and teaches
5

seminars on human movement. For more information, please visit

www.pinnacle-tcs.com.

REFERENCES
Bernhardsson, B., et al (2012), Evaluation of an exercise concept
focusing on eccentric strength training of the rotator cuff for patients
with sub acromial impingement syndrome, Clinical Rehabilitation, pp.
1-9.
Chester, R., et al. 2010, The impact of subacromial impingement
syndrome on muscle activity patterns of the shoulder complex: a
systematic review of electromyographic studies
BMC Musculoskeletal Disorders, vol. 11, issue 45, pp 1-12.
Holmgren, T., 2012, Effect of specific exercise strategy on need for
surgery in patients with sub acromial impingement syndrome:
randomized controlled study, British Journal of Medicine,
pg. 344.
Kuhn, J., 2009, Exercise in the treatment of rotator cuff impingement:
A systematic review and a synthesized evidence-based rehabilitation
protocol, Journal of Shoulder Elbow Surgery, vol. 18, pp. 38-160.
Ludewig, P., 2011, Shoulder Impingement: Biomechanical
Considerations in Rehabilitation,
Journal of Manual Therapy, vol. 16, issue, pp. 3339.